A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?
The client's heart rate is 110/min.
The client is guarding their abdominal incision.
The client exhibits facial grimacing.
The client reports pain.
The Correct Answer is D
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Potassium
Rationale:
A) Potassium:
Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious cardiac arrhythmias and muscle weakness. Ensuring potassium levels remain within a normal range helps maintain the infant's overall health and safety while on this medication.
B) WBC Count:
While it is important to monitor WBC count in various clinical situations, furosemide does not typically affect white blood cell levels. Therefore, monitoring WBC count is not specifically indicated for infants receiving furosemide unless there is another underlying condition that requires it.
C) Iron:
Iron levels are not typically affected by furosemide. Monitoring iron levels would be more relevant in cases of anemia or other hematologic conditions. Furosemide does not interfere with iron metabolism, so this test is not a priority for infants on this medication.
D) Amylase:
Amylase is an enzyme related to the pancreas and is typically monitored in conditions such as pancreatitis. Furosemide does not have a direct effect on amylase levels, so monitoring this enzyme is not necessary for infants receiving this diuretic. The focus should be on electrolytes, particularly potassium.
Correct Answer is A
Explanation
The nurse should administer scheduled pain medications to a client who is near death. This is an important nursing intervention to ensure that the client is comfortable and free from pain.
b) Providing oral care every 6 hours is important, but it may not be the highest priority for a client who is near death.
c) Administering liquids using a syringe may not be necessary or appropriate for a client who is near death.
d) Whispering when talking to family members is not necessary. The nurse should communicate openly and honestly with the family members.
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